Rehabilitation Plan and Award

Forms and Documents

Document Name	Status
Form OWCP-16 Rehablitation Plan and Award Form and Instruction	Modified
Pay & Leave Salaries & Wages - OPM_gov.mht Supplementary Document	2014-04-22
Privacy Act System of Records- Longshore.docx Supplementary Document	2014-04-22
Privacy Act Systems - DOL-GOVT-1.docx Supplementary Document	2014-04-22
Longshore 702.506 and 702.507.docx Supplementary Document	2014-04-22
20 cfr 10.518 and 20 cfr. 10. 519.docx Supplementary Document	2014-04-22
SS 1240-0045 (OWCP-16).doc Supporting Statement A	2014-05-28

IC Document Collections

IC ID	Document Title	Status
13717	Rehablitation Plan and Award Form and Instruction	Modified

ICR Details

OMB Control No: 1240-0045	ICR Reference No: 201403-1240-003
Status: Historical Active	Previous ICR Reference No: 201011-1240-005
Agency/Subagency: DOL/OWCP	Agency Tracking No:
Title: Rehabilitation Plan and Award
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/15/2014
	Date Received in OIRA: 07/15/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2017	36 Months From Approved	09/30/2014
Responses	4,590	0	5,500
Time Burden (Hours)	2,295	0	2,750
Cost Burden (Dollars)	0	0	0

---

Abstract: Form OWCP-16 is used by vocational rehabilitation counselors to submit an agreed upon rehabilitation plan to OWCP for approval, and documents OWCP's award of payment for any approved services.

---

Authorizing Statute(s): US Code: 5 USC 8101 et seq. Name of Law: Federal Employees' Compensation Act (FECA)
   US Code: 33 USC 901 et seq Name of Law: Longshore and Harbor Workers' Compensatinon Act (LHWCA)
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 17193	03/27/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 41305	07/15/2014
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Rehablitation Plan and Award	OWCP-16	Rehabilitation Plan and Award

---

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	4,590	5,500	0	0	-910	0
Annual Time Burden (Hours)	2,295	2,750	0	0	-455	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Over the last three fiscal years (FY 2011-2013), open rehabilitation cases have averaged 4, 590, which is 910 less than the number reported (5, 500) for the previous submission in 2011. As a result in reduction in Rehabilitation Plans, burden hours have decreased 455 hours, from the previous submission of 2,750 to 2,295. As previously indicated in item 12, there are no costs for burden hours as the respondents are contractors and are remunerated for their services and expenses by OWCP. Revisions of the form itself include the following changes: The form was expanded to two pages to allow for more sufficient space to complete it. Additionally, in item 15 of the form, the reference to the District of Columbia Compensation Act was removed as the DC government is responsible for administering their own program. This was previously administered by Longshore. Additionally, an accommodation statement was placed on the form to inform claimants who have mental or physical limitations to contact DFEC if further assistance is needed in the claims process. Finally, the Privacy Act and the Public Burden statements were revised.

---

Annual Cost to Federal Government: $204,826

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 07/15/2014

---